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May 20, 2024

Targeted Probe & Educate Update: January – March 2024

The information below describes the CGS J15 Home Health & Hospice Targeted Probe & Educate (TPE) program's progress from January through March 2024.

Findings

Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education throughout and upon completion of each round of TPE review. TPE results for home health and hospice services are listed below.


Home Health Probes Completed

Current Edits

The primary focus of these reviews is to determine if medical record documentation supports Medicare guidelines for medical necessity of the services billed. Current home health edits for TPE include:

Review Topic Edit Numbers Description Review Type
Medical Necessity 5A007 5B007 5C007 This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. TPE Prepayment Review
New Providers 5A006 5B006 5C006 This edit selects home health claims for relatively new providers who have submitted at least 50 claims. TPE Prepayment Review
Medical Necessity 5N000 5T000 5V000 This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. TPE Round 1 Postpayment Round 2 Prepayment Round 3 Prepayment

Results

Results 5A007 Round 1 5B007 Round 2  5B006 Round 2 5C006 Round 3 5T000 Round 2
Probes Completed 5 13 5 1 3
Providers Compliant after Round Completion 1 3 4 0 2
Providers Non-compliant after Round Completion (advancing) 4 10 1 1 1
Providers with Non-Responses to ADRs for Round 1 0 1 0 1
Education contacts 3 17 1 1 3

Findings by State

Summary of review findings for providers that completed rounds of review (by State):

Review findings

Review findings

Top Denial Reasons

  1. Skilled nursing not medically necessary (5HN18)
  2. Initial certification invalid (5HC09)
  3. Therapy visits not medically necessary (5HY01)
  4. F2F missing/incomplete/untimely (5HC01)
  5. Medical records not received (56900)

Hospice Probes Completed

Current Edits

The primary focus of these reviews is to determine if medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current hospice edits for TPE include:

Review Topic Edit Numbers Description Review Type
LOS with Non-Oncologic Diagnosis 5D000 5E000 5F000 This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code TPE Prepayment Review
GIP LOC 5D006 5E006 5F006 This edit selects hospice providers who submitted claims with revenue code 0656 greater than or equal to 7 days TPE Prepayment Review
New Providers 5D008 5E008 5F008 This edit selects hospice claims for relatively new providers who have submitted at least 50 claims. TPE Prepayment Review
LOS 313-515 days 5D010 5E010 5F010 This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code TPE Prepayment Review

Results

Results 5D008 Round 1 5E008 Round 2 5D010 Round 1 5E010 Round 2 5D006 Round 1 5E000 Round 2
Probes Completed 6 10 13 1 1 3
Providers Compliant after Round Completion 1 6 0 0 1 1
Providers Non-compliant after Round Completion (advancing) 5 4 13 1 0 2
Providers with Non-Responses to ADRs for Round 0 0 2 0 0 1
Education Contacts 13 10 21 1 2 5

Findings by State

Summary of review findings for providers that completed rounds of review (by State):

Review findings

Review findings

Top Denial Reasons

  1. Notice of Election invalid (5PX06)
  2. Terminal prognosis not supported (5PM01)
  3. Face-to Face encounter invalid (5PC08)
  4. Medical records not received (56900)
  5. Physician narrative missing/invalid (5PC01)

Education

CGS offers providers with a moderate to high error rate an individualized education session in which each claim found in error is discussed and any questions answered. These education sessions may occur via webinar, web-based presentation, or traditional teleconference. Other methods may also be available. Providers may also submit questions or request education via email: J15HHPROBEANDEDUCATION@CGSADMIN.COM.

Next Steps

At the completion of Round 1/2, providers identified as non-compliant will advance to Round 2/3 of TPE at least 45 days from the 1:1 post-probe education call completion date. CGS offers provider education at any time, and you may request education even if you aren't selected for TPE. CGS encourages providers to request education, conduct self-monitoring based on our Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) offered through our myCGS portal.

References

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